VAmalpractice.info Information on medical malpractice, crime, fraud and other things that adversely affect the quality of medical care that veterans receive from the VA! Lawyers who represent veterans with medical malpractice cases against the VA.

Colmery-O’Neil VA Medical Center physician Jose Bejar avoided trial in Shawnee County on nearly two dozen counts of sexual misconduct by pleading no contest to two charges of conducting inappropriate pelvic and breast examinations on patients.

Charges were filed after five female veterans who were patients at the Topeka hospital claimed mistreatment at the hands of Bejar from 2007 to 2011. Bejar, fired by the U.S. Department of Veterans Affairs in May, lost his medical license and must register as a sex offender.

Bejar’s employment at Colmery-O’Neil overlapped briefly with that of physician Kayode Sotonwa, who was hired within two years of acquittal on Florida charges he sexually abused multiple patients by performing breast and pelvis examinations unrelated to their medical needs. Prosecutors there said 16 patients filed complaints against Sotonwa, but the doctor was welcome at Colmery-O’Neal in 2011 and 2012 before taking a job in Texas. During Sotonwa’s tenure, two other Colmery-O’Neal doctors wrote dozens of prescriptions to an administrative colleague for nearly 4,000 powerful painkillers in a 12-month period. The transactions are under investigation by the VA.

These issues arise amid concern about Colmery-O’Neil’s officials diverting sick veterans to other hospitals for months due to a shortage of physicians that already had state and federal elected officials asking questions about the facility’s management.

Rep. Lynn Jenkins, R-Kan., sent a letter to U.S. Veterans Affairs Secretary Eric Shinseki when the staffing issues surfaced.

“I’ve been contacted by a great number of current and former employees of the Topeka VA, as well as patients, and I’ve become increasingly concerned,” Jenkins said Thursday. “As we’ve looked into some of the staffing issues we’ve uncovered a growing number of complaints about quality of care, the employee culture and just the overall work environment.”

Jenkins said she has a meeting scheduled with Rudy Klopfer, the director of the VA Eastern Kansas Health Care System, who has promised her a “top-to-bottom” review.

Rajeev Trehan, chief of staff of the VA Eastern Kansas, said sexual abuse allegations are taken seriously, potential hires are reviewed thoroughly, and new procedures have been implemented to improve tracking of prescriptions. Trehan, a physician, said Colmery-O’Neil and its partner hospital in Leavenworth measure up well to other VA facilities in the Midwest.

Klopfer, who was hired from a VA hospital in North Carolina last year, said Colmery-O’Neil provides care equal to any comparable private-sector facility. But he also said it is his responsibility to “hold individuals accountable.”

“Any time one of our veterans is hurt or impacted negatively by one of our staff members, that’s awful,” Klopfer said. “That’s not called for, and it’s not a common practice here.”

Bejar’s downfall

Topeka police arrested Bejar, a neurologist, in May 2012.

Jim Gleisberg, spokesman for the VA Eastern Kansas, said Bejar was suspended without pay on July 5, 2012, and terminated on May 21, 2013.

Bejar, now 67, received a 32-month suspended sentence on May 3, 2013, and was released under county supervision.

Five female veterans told prosecutors that between 2007 and 2011 Bejar violated them by conducting unnecessary “breast examinations” and at least one unnecessary “pelvic examination” that included vaginal penetration.

“I think the fact these five women were willing to testify says a lot about what he did to them,” said Todd Hiatt, a senior assistant district attorney in the Shawnee County District Attorney’s Office.

A message left Monday at the office of Bejar’s attorney, former Kansas Attorney General Paul Morrison, wasn’t returned.

Bejar has filed a lawsuit in federal court, claiming he was “the victim of a well-organized conspiracy.”

The suit says Bejar, a native of Ecuador, was framed because of his “race and national origin” and in retaliation for multiple discrimination complaints he filed with the federal Equal Employment Opportunity Commission since Colmery-O’Neil hired him in 1988.

Hiatt disagreed.

“Our charges were based on the statements of five women who didn’t know each other and didn’t conspire together,” Hiatt said.

Court documents show the VA’s Office of Inspector General investigated Bejar for months before forwarding complaints to Topeka law enforcement.

Cathy Gromek, a spokeswoman for the inspector general’s office in Washington, D.C., said the office won’t comment and Kerry Baker, the agent who investigated the claims against Bejar, won’t be made available for an interview. An open records request is pending.

Klopfer said the inspector general’s investigation stemmed from an internal probe at Colmery-O’Neil that resulted in Bejar being placed on administrative leave in 2011.

“When the allegations came forth of what occurred, immediately he was put on authorized absence and was not allowed to see patients,” Klopfer said. Trehan said the VA has “become very sensitive to women’s issues and women’s complaints.”

“The threshold is really low, if there’s allegations,” Trehan said.

Joyce Grover, executive director of the Kansas Coalition Against Sexual and Domestic Violence, said connections can be drawn between Bejar’s abuse of female veterans and reports of high incidence of sexual abuse of female armed services members on active duty.

“To me, it seems it’s an issue that continues on, in terms of this being a vulnerable population within the military,” Grover said.

Grover called Bejar’s abuse “really disheartening.”

“It’s depressing to know, and sad to know, this is happening here,” Grover said.

Bejar faced 22 charges of sexual battery before pleading down to two: a felony count of aggravated sexual battery for the pelvic exam and a misdemeanor count related to the questionable breast exams.

Hiatt said getting the felony conviction was top priority, but the attached misdemeanor charge was key to validating the claims of the other women.

With no prior criminal record, Hiatt said the 32-month suspended sentence was the most extensive penalty Bejar was likely to get if he had taken the case to trial. By accepting the plea of no contest, Hiatt spared the victims the pain of having to testify.

“It wasn’t worth traumatizing those women again,” Hiatt said.

Sen. Laura Kelly, D-Topeka, said Bejar’s conviction should be cause for change.

“I would hope that someone in Washington has come down hard on the VA administration, held them accountable and ensured that this kind of abuse never happens again,” said Kelly, whose father was career military. “We owe that much to our veterans.”

The Florida case

News reports and medical licensing documents out of Florida outline the sexual abuse case that developed against Sotonwa — arrested on charges of sexually abusing patients, multiple victims coming forward, accusations of inappropriate pelvic contact and unnecessary breast exams, one reportedly lasting as long as 15 minutes.

But Sotonwa fought the charges and a jury found him not guilty in May 2009. Two years later, he was practicing at Colmery O-Neil.

Federal employee databases show that Sotonwa was hired at an initial salary of $175,000 in 2011. His pay was upped to $213,000 in 2012. Gleisberg said Sotonwa has since been promoted to a new VA job at a hospital in Big Springs, Texas.

The staff there said Sotonwa was out of town and not available for comment, but VA public affairs officer Jean Schaefer released a statement highlighting the VA’s “extensive” employment screening process.

“As you may be aware, Dr. Sotonwa was acquitted of charges related to his employment in Florida,” Schaefer said.

Roy Danks, a former Colmery-O’Neil physician, said Sotonwa’s history was common knowledge among the staff at the Topeka facility and made some uncomfortable.

“Was due diligence done?” asked Danks, who now practices in Great Bend. “Maybe it was and part of it was ignored.”

Danks, an Army Reservist with experience as a trauma surgeon in Iraq and Afghanistan, was hired by Colmery-O’Neil on a limited basis last year after his wife became a salaried internal medicine physician at the hospital.

Within months both decided to leave, with Danks citing a leadership void and bureaucratic turf wars as contributing factors. Still, he said he wouldn’t describe himself as a “disgruntled former employee.”

“I’m very content in Great Bend right now,” said Danks, 46.

Klopfer said the VA screening process, VetPro, is thorough enough that it would have revealed the past charges against Sotonwa before Colmery-O’Neil hired him.

“My expectation is that due diligence and that rigorous review did indeed occur there and based upon that (it was determined) he was appropriate to come on board,” Klopfer said. “I do know there have not been any incidents here at Eastern Kansas while he worked here. He no longer works here.”

Trehan said charges of patient abuse, minus a conviction, wouldn’t necessarily disqualify a candidate in the hiring process.

“People who’ve been in practice have sometimes been the victim of complaints, lawsuits, things of that kind,” Trehan said. “So, depending on their background, history of practice, that is not unusual. People have things happen in their work life. That on the very face of it is not a disqualifier. But we go through it carefully.”

When asked what would be an automatic “deal breaker” when looking at a candidate, Trehan said the absence of an unrestricted license to practice medicine is the threshold.

Records from the Florida Department of Health show Sotonwa’s license to practice in that state was suspended on an emergency basis in 2008 after the Largo Police Department began investigating abuse complaints against him.

But the health department’s website shows his license is active again, and he also claims to be licensed in Pennsylvania, Michigan and Mississippi.

As a federal agency, the VA requires licensure in only one state for a doctor to practice at any VA facility.

Kendall Davidson, one of the Pinellas-Pasco State Attorney’s Office attorneys who prosecuted Sotonwa’s case, didn’t respond to a phone message left at his office. But Davidson told the Tampa Tribune in 2009 that a total of 16 patients lodged complaints against Sotonwa.

Davidson and his colleagues pursued charges related to only three of the alleged victims, each of whom Sotonwa’s attorneys sought to discredit at trial by pointing out their histories of mental illness and, in one case, a criminal record.

Jurors ultimately were swayed in Sotowna’s favor.

Sotonwa denied the allegations from the start, reportedly saying of one of his accusers, “Why would I do that? Have you taken a good look at her? I am not desperate.”

The prescriptions

While Bejar and Sotonwa were practicing at Colmery-O’Neil in 2011, two colleagues began writing prescriptions for 3,810 pain pills, muscle relaxants and anti-anxiety drugs in one year for a fellow employee.

Documents provided to The Capital-Journal show an administrator on duty at Colmery-O’Neil with a 2012 salary of $53,773 filling 35 prescriptions for diazepam (previously sold under the brand name Valium), hydrocodone-acetominophen (commonly known as Vicodin or Lortab) and carisoprodol (brand-name Soma).

The prescriptions, filled at four separate Walgreens locations, were nearly all written by one VA doctor. Three were written by another doctor also practicing at Colmery-O’Neil.

The documents show that all the prescriptions were filled between August 2011 and July 2012. As the year went on, the dosage of both drugs in the hydrocodone-acetominophen mix increased, ending at 10 milligrams hydrocodone combined with 500 milligrams of acetominophen. The diazepam dose stayed steady at 10 milligrams and the carisoprodol at 350 milligrams.

While not commenting on specific patients or employees, Trehan said that, in his professional opinion, such dosages could impair a person’s ability to work, depending on whether the patient had built up a tolerance.

“If they got the drugs overnight at that dose it would put them to sleep, or in a coma,” Trehan said. “However, if they’ve grown to that dose and usage over the years, they could be on a huge amount and function perfectly fine, no impact.”

Trehan said Colmery-O’Neil has no policy against in-house providers writing prescriptions for employees because some Colmery-O’Neil workers also are veterans and VA patients.

“If people are prescribing based on their personal equation, we don’t police that as long as they’re not using the VA’s resources — not using the VA pharmacy,” Trehan said. “If people have personal friendships on the outside, or acquaintances or practices, we don’t prohibit people from practicing.”

Trehan also said Colmery-O’Neil has tightened its prescription controls this year, moving from a paper and pencil model to a fully computerized system that requires providers to enter their ID card into the keyboard.

“The VA system of prescribing within the VA is about as airtight as you can get,” Trehan said.

Klopfer said privacy concerns prevent the VA from zeroing in on specific patients, but the organization does track provider prescription patterns.

“We do know what our providers are prescribing, and we can pull up reports for that,” Klopfer said.

Gleisberg said Colmery-O’Neil officials began the investigation into the pain pill prescriptions before passing it along to the inspector general’s office, which is still investigating.

Implications

Klopfer said he wasn’t aware of the Bejar prosecution or the ongoing prescription drug investigation when he was hired last year. But he expressed confidence in his staff and said his pre-hire research revealed a system that was, overall, providing quality patient care.

“As a director you go into a situation that’s not perfect and you want to improve,” Klopfer said. “But the key thing is, we’re serving veterans.”

Klopfer said the staff at Colmery-O’Neil is professional and competent and the hospital is, on the whole, a great place to work. But he said he holds the facility to a high standard and will act if it falls short.

“If any veteran is harmed, I’ve got to look at it,” Klopfer said. “Examine what occurred and take the necessary steps to change that. They’ve got to understand when they come here they are safe and the care they are getting is high quality, because they served us and our country.”

“I know that Congresswoman Jenkins has initiated an inquiry into concerns at the VA,” said Schmidt, whose district includes Colmery-O’Neil. “I look forward to working with her to make sure our veterans get the medical care they need.”

If you were a kid growing up in the decade after World War II, it seemed as if the then-Veterans Administration hospital was where dads went to die. We had come to expect more in the last 60 years. And that is why the recent discovery of the fatal outbreak of Legionnaires’ disease at the VA Pittsburgh Healthcare System is so jarring.

Through the early 1950s, it was grim news if your loved one, who had returned broken from the war, relapsed or slowly deteriorated to the point that he was admitted to the local VA hospital. Prospects of a second homecoming seemed bleak. But bad as it was, it never was about blame.

While those were sad times, they were sad for everyone, not a street spared the tragedy of war. If a family did not lose someone over there, they were considered lucky to have had a little extra time with them back here, before the wages of war were called due.

And while the medical staff did what they could at the VA, the damage was often great and treatment was far from cutting edge. New hospitals could not be opened fast enough to treat the WWII veterans, the bed shortage growing worse as vets returned from Korea. It was sacrifice without end.

So you could forgive a kid back then for thinking that his war-tattered dad would not be coming home again if he was sent to the VA. In time, however, even those impressions faded, life improved, science progressed, more wars came and went of course, and the country, and the VA, seemed up to it.

But a recent House Committee on Veterans Affairs investigation casts doubt on veterans’ health care. A Legionnaires’ disease outbreak that occurred at the Pittsburgh VA hospitals starting in 2011 sickened as many as 21 veterans and killed at least five, according to the Centers for Disease Control and Prevention.

And the Trib’s own investigation of this latest outbreak discovered evidence of deadly bacteria in the Pittsburgh VA water system as early as 2007. Worse, this recent outbreak was not disclosed until November 2012 and a tone-deaf VA awarded cash bonuses to the administrators in charge of this system in spite of the tragedy.

Too often, bad news about the VA is about health care, the inability to get veterans treatment or its haphazard nature when it is delivered. Could it be that the sorry state of health care nationally, for the rest of us, has tainted veterans’ health care, making it easy to set the bar low?

The chief of staff at VA Pittsburgh hospitals, Dr. Ali Sonel, has blamed the outbreak on “flawed” testing procedures and a “deadly myth” that there is a safe level of bacteria. And, according to Sonel, other area hospitals have admitted to operating under those same policies.

It can break your heart, hearing about it happening again, happening now. All these decades later, after fighting his war, returning to build a great nation and raise a family, doing his best as a father, friend and neighbor, you would think that a dad could enter the VA hospital, get treated and return back home.

VA declares victory over quality of care issues, despite the facts.

or

“Maybe they’re drinking too much of their own Kool-Aid”

The September 25, 2013, VA OIG’s report “Quality of Care Issues: Erie VAMC & VA Pittsburgh Health System” is yet another in a series which should be called “More news from Michael Moreland and VISN 4.” The OIG’s 11 page report tells a sorry story about the medical treatment that a veteran received from August 15, 2102 through October 1, 2012 for his liver cancer, it tells an even sorrier tale about the “treatment” that this veteran and his family received from an institution that has the audacity to spend the taxpayer’s money to advertise that “it is better than the best.” These six weeks turned out to be the only medical care that the veteran would ever receive from the VA, as he died on October 6, 2012.

The OIG found:

We substantiated the allegation that VA providers did not diagnose the patient’s cancer..

We found VA providers missed opportunities to identify the patient’s cancer and determined several factors that may have contributed to providers not making the cancer diagnosis…

We substantiated the allegation that the patient’s pain was not fully addressed…

We substantiated the allegation that there were scheduling delays in the patient’s referrals and follow-up care…

We substantiated the allegation that this patient did not receive comprehensive oversight through the continuum of his care…

During interviews, many referring providers from the CBOC, Erie VAMC, and Pittsburgh HSC told us it was difficult to communicate with the gastroenterology and Hepatology Clinic specialists. They told us their phones calls occasionally go unanswered and the specialists did not always return phone messages.

Unfortunately none of these finding are surprising; but what is amazing is the indifference to reality that allows the VISN 4 leadership to continue their tireless campaign of self-promotion and disinformation at the expense of the taxpayers. Let’s look at the dates of this veteran’s treatment and a few other things that were happening in VISN 4:

8/15/2012 Veteran’s first contact with VA system

9/30/2012 End of VA’s fiscal 2012 year (This is the year that Michael Moreland received the $63,000 presidential award for)

9/30/2012 VISN 4 is rated the worst in the country using the VA’s own ASPIRE quality measurement system for Ventilator Acquired Pneumonia

10/01/2012 Veteran’s last of 13 contacts with VA system since 8/15

10/06/2012 Veteran Dies

Fall 2012 VISN 4 “Vision for Excellence” features stories proclaiming that healthcare provided to veterans in VISN 4 is better than the health care provided by the top 5 hospitals in the nation.

Page 12 of the Fall 2012 VISN 4 “Vision for Excellence”

Despite the tragic care that this veteran received, the fall 2012 Vision for Excellence had no trouble extolling the quality of the medical that VISN 4 delivered to veterans and pointed out that its ad campaign “Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. I’ve seen this ad and it unilaterally declares that VISN 4 “beat” the competition in vague areas like “patient satisfaction” by statistically insignificant percentages. With no explanation if these figures were gathered in the same manner at VA and nonVA institutions, Mr. Moreland enthusiastically claims that VISN 4 took on the likes of Johns Hopkins and won! The odds are pretty good that the veteran in this OIG report, along with a few who died from Legionnaires’ disease probably didn’t return their patient satisfaction surveys, but if they did they might disagree with Mr. Moreland’s evaluation. No matter what you’ve got to give Mr. Moreland credit, not everyone can get up and say that we are better than the best when you’re in the midst of a Legionnaires’ disease outbreak, a congressional investigation and you have the worst record in the entire VA ventilator‐associated pneumonias.

Ironically, nowhere in this “public service announcement” does Mr. Moreland mention that VISN 4 had the worst ventilator acquired pneumonia rate in the entire VA system. Out of the VA’s 23 VISNs, VISN 4’s record was twice as bad as the second worst VISN. This sort of head to head meaningful comparison would have provided veterans with meaningful information and would have been a “public service” because it would have warned veterans that they would have been better off going to any VISN besides VISN 4 if they were concerned about possibly getting ventilator‐associated pneumonia. Instead Michael Moreland just uses a lot of fuzzy math and unilaterally declares victory over all quality of care issues in VISN 4 and led veterans to believe that all is well. This superior level of chicanery did not go unnoticed in Washington, where this sort of thing is considered career enhancing and resulted in appropriated recognition:

…“Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. This campaign won first prize in VHA’s annual communications awards program in 2012.

9/6/2013 Michael E. Moreland endorses the OIG report for the veteran who was treated so poorly at the Erie, VA, prior to his testimony at the 9/9/2013 HVAC hearing to examine preventable deaths and accountability at the VA. That must have put him in the right mood for the hearing. Maybe that’s why he looked so green?

Michael Moreland endorses OIG report finding medical malpractice at the Erie VA and Pittsburgh VA 3 days before he testifies at the HVAC hearing on Preventable Deaths and Lack of Accountability at the VA

Despite the overwhelming evidence contained numerous VA OIG reports and congressional investigations confirming patient safety lapses in VISN 4, during the last five years, VISN 4 continues to spend money explaining how it has done such a wonderful job dealing with patient safety.The VISN 4 web site continues to boldly state:

When VISN 4 compared its ability to provide quality health care with the best hospitals in the United States, we equaled or exceeded our competition in every category. This is proof that our nation’s heroes are being provided the quality of health care that they richly deserve.

Its most recent issue of “Vision for Excellence” it again extols how much VISN 4 has done in this area. This will be the subject of a future post called “VISN 4’s medical care “quality” publicity blitz, twisting the facts: Delusional fantasy, or indictable fraud?

Shortages of beds, doctors and nurses in the Baltimore VA Medical Center’s emergency room resulted in nearly half of a sample of patients spending more than 6 hours at the facility, including one who waited more than 24 hours, according to a critical inspection report released this month.

In that case, a 59-year-old woman who reported a racing and pounding heartbeat waited 24 hours, 8 minutes before being admitted to a unit where her heartbeat could be continuously monitored. In another example, a 52-year-old man with schizophrenia who expressed desires to kill himself or others waited 22 hours until he was transferred to a non-VA hospital for treatment.

The Department of Veterans Affairs inspector general’s office detailed the shortcomings in a report that criticized the hospital’s leadership for lacking policies to provide on-call doctors and nurses to boost staffing when patient volume surged. Backups in treating patients led to some being examined in the emergency department’s triage area, without privacy, the report said.

The findings come to light as Baltimore’s VA office is scrutinized for being second-slowest in the country at processing disability claims. Earlier this month, Sen. Barbara A. Mikulski demanded that the agency immediately develop an action plan to improve efforts at speeding claim processing.

The inspectors visited the hospital in November 2012. In a response written in July to the report, VA hospital officials pledged changes, some of which it put in place this past spring. Veterans’ advocates said they plan to closely monitor conditions at the hospital to ensure that patient care is improved.

“The concern is that they’re not able to get up to the ICU or to be in an inpatient unit without the proper staffing levels,” said Jacob Gadd, deputy director for health care for the American Legion, which monitors veterans’ health care quality across the country. “We’re thankful no veterans were harmed because of the staffing levels.”

The inspection found that of a sample of 20 patients on high-volume days, nine spent more than six hours in the emergency department, and six spent more than 20 hours, with an average length of stay of 7.9 hours. Veterans Affairs standards require that no more than 10 percent of emergency patients spend longer than six hours in the facility, the report noted.

Inspectors found that patients often complained about the lengthy wait times. While hospital leaders routinely reviewed patient data each day, they did not review data on patients’ length of stay, the report said.

The backlogs frustrated staff too, the report said.

“Although we did not find examples of patients suffering adverse events due to staffing shortages, we did find a dedicated staff that felt frustrated by what they perceived as an inability to provide the quality of care their patients deserved due to staffing shortages,” the report said.

The inspectors found that the problems stemmed from an inability to boost staffing during busy times and a lack of a policy outlining how the department would handle patients when it lacked the appropriate beds or enough staff to care for them.

In responses to the inspection appended to the report, leaders at the Baltimore hospital concurred with the report and said improvements were underway. The hospital added extra beds in a unit capable of cardiac and other monitoring, changed schedules for doctors and physician assistants to accommodate expected periods of high patient volume, and improved its on-call systems. The number of nurses assigned to the emergency department also was increased, the response said.

Hospital officials said patient waits have already improved in the emergency department. During the first six months of 2013, the average visit time for patients who were not admitted to the hospital was between three and four hours and the proportion of patients staying six hours or longer fell to 12 percent, they said.

They added that their own assessment of data for patients who stayed longer than six hours revealed that, in many cases, a patient’s stay was lengthened because of a need to treat for intoxication before a mental health assessment can be performed.

VA officials did not respond Thursday to requests for comment.

The West Baltimore hospital, adjacent to the University of Maryland Medical Center, has about 700 beds and sees about 8,300 patient admissions and 622,000 outpatient visits annually, according to American Hospitals Association data.

Luis Fábregas is an award-winning reporter who specializes in medical and healthcare issues as a member of the Tribune-Review’s investigations team.

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By Luis Fábregas

Published: Saturday, December 1, 2012 10:36 a.m.

If anyone should know about Legionnaires’ disease, you’d think it would be the folks at the VA Pittsburgh Healthcare System.

Long before an outbreak of the illness this month struck five patients at the University Drive hospital in Oakland — killing one — the VA housed a laboratory of the nation’s leading researchers in Legionnaires’ disease.

The lab’s Dr. Janet Stout in 1981 identified common tap water as the source of Legionella. Another scientist there, Dr. Victor Yu, identified and tested effective antibiotics for the bacteria, which can cause a deadly form of pneumonia. They also identified other undiscovered pathogens of human illnesses and became leaders in antibiotic-resistant bacteria.

Stout and Yu received recognition from the American Legion — the veterans group hosting a 1976 convention at the Bellevue-Stratford Hotel in Philadelphia where the first outbreak occurred. Thirty-four died and more than 200 were sickened.

You’d think the VA would have been happy with the acclaim for identifying the source, not to mention the lab’s ability to test samples from hospitals across the nation. For reasons that remain unclear, the VA shut down the lab in 2006. They fired Yu, and Stout later resigned.

VA officials soon after ordered the destruction of a collection of thousands of Legionella samples that represented more than 30 years of medical research. One VA official said during a 2008 congressional hearing that the lab was not productive and was “a drain on clinical resources.”

The collection included Legionella pathogens and patient specimens collected from outbreaks worldwide, yet VA officials discarded them as if they were garbage.

Sadly for the affected patients and their families, the VA had this outbreak at University Drive coming. Administrators shut down an important laboratory without considering the implications.

“This absolutely will jeopardize lives,” Yu told the Trib in 2006 when his lab closed.

Yu, who now operates a special pathogens lab across the street from UPMC Mercy, Uptown, told me this week that the recent outbreak at the VA University Drive was completely preventable. He has warned hospitals that vigilance and expertise are crucial for sustained disinfection of cooling systems in large buildings, where Legionella bugs thrive.

The folks at the VA haven’t said much about the outbreak, other than saying they’ve acted “swiftly” to contain it. Had they not destroyed the valuable collection of pathogens six years ago, they might have resurrected organisms found at the University Drive facility to assess whether the newly found bacteria had acquired resistance to disinfection treatments.

The VA has started using a chlorination method to disinfect the water distribution in place of the copper-silver commonly used in hospitals. The Centers for Disease Control and Prevention endorses chlorination as the best strategy, but questions remain: Was the copper-silver method really to blame for the outbreak or did it occur because the VA was not adequately monitoring and flus

More than 5 months after the US attorney arrested and accused Richard Meltz of “bone chilling conduct”, his photo remains prominently displayed on the Lyons, NJ VA Medical Center Police Department web site:

Despite the fact that he had been promoted and left the Lyons New Jersey VA, and even more surprisingly despite the fact that he had been arrested on April 15, 2013, as of September 22, 2013 the Lyons New Jersey VA Police Department’s unofficial website still features a picture of Richard Meltz indicating that he is a sergeant and a firearms instructor at the Lyons, NJ VA. Is there no accountability whatsoever at the Lyons VA?

Maybe it doesn’t bother anyone there to be associated with someone who has been arrested for attempted kidnapping? One would think that they would have taken his photo down the day that he was arrested, but give their history maybe their proud to be associated with him.

Manhattan U.S. Attorney And FBI Assistant Director-In-Charge Announce Kidnapping Conspiracy Charges Against Massachusetts Veterans Affairs Police Chief And Former New York City High School Librarian

Preet Bharara, the United States Attorney for the Southern District of New York, and George Venizelos, the Assistant Director-in-Charge of the New York Office of the Federal Bureau of Investigation (“FBI”), today announced the arrests of RICHARD MELTZ, Chief of Police for the U.S. Department of Veterans Affairs, for the Bedford, Massachusetts Veteran Affairs Medical Center, and ROBERT CHRISTOPHER ASCH, a former high school librarian, for conspiracy to kidnap, torture, rape, and kill women and children. MELTZ was arrested yesterday afternoon and ASCH was arrested this morning by special agents of the FBI. MELTZ and ASCH will be presented today before U.S. Magistrate Judge James C. Francis IV in Manhattan federal court.

Manhattan U.S. Attorney Preet Bharara said: “The bone-chilling conduct alleged in this complaint is a chronicle of sadism and depravity that includes the defendants’ very real steps to carry out their plans to kidnap, torture, rape, and kill the women and children they targeted. As alleged, Richard Meltz and Robert Christopher Asch assiduously planned their plot in detailed conversations and alternately served as advisors and facilitators of the plan – Meltz provided ‘strategic advice’ and Asch conducted surveillance, and provided supplies including leather ties, a sleeping agent, instruments of torture, and a taser gun. The only thing that stood between these alleged kidnappers and their horrifying plot was the outstanding investigative teamwork of the FBI and the prosecutors in this Office.”

FBI Assistant Director-in-Charge George Venizelos said: “As alleged, both of these defendants took affirmative steps to carry out the conspiracy to kidnap and torture women. Their actions were not confined to talking about these ghoulish plans. They acquired the tools to accomplish the deed, including a taser and the chemical means to anesthetize their victims. And they made detailed plans to use these instruments – plans that were foiled by the FBI’s intervention.”

According to the Complaint filed today in Manhattan federal court:

Between 2011 and October 2012, MELTZ, ASCH, and a co-conspirator, Michael Vanhise, who was previously indicted on kidnapping conspiracy charges, engaged in a series of electronic mail (“e-mail”) and instant message communications during which they discussed and planned in great detail the kidnapping, torture, and murder of women. In October 2012, FBI agents became aware of these communications. Specifically, they learned that Vanhise was sending e-mail and instant messages from various computers to solicit individuals, including MELTZ and ASCH, to kidnap, rape, and kill his wife, his sister-in-law, her children and his step-daughter. Vanhise eventually met with FBI agents, and told them that he sent MELTZ and ASCH photographs of his sister-in-law and her minor children. MELTZ and ASCH both expressed interest in kidnapping the proposed victims, and Vanhise provided MELTZ and ASCH with a location that was in close proximity to the kidnapping targets’ actual home address. In an e-mail exchange between MELTZ and Vanhise about this plan, MELTZ wrote: “we go over there she know you let’s [sic.]us in we choke her out tie her up throw her in the back of your car take her someplace and [rape and torture her].”

In October 2012, an FBI agent working in an undercover capacity (“UC-1”) contacted ASCH online and began discussions about kidnapping a woman, who, unbeknownst to the defendants, was also actually an FBI undercover agent (“UC-3”). UC-1 and ASCH met on a number of occasions in Manhattan, and during one such meeting on March 13, 2013, ASCH provided UC-1 with a bag of materials to be used during the kidnapping and torture of UC-3, including a ski mask, hypodermic needles, leather ties, chrome forceps, a three-page gun show itinerary, documents relating to a “leg-spreader” and “dental retractor” that ASCH claimed to have purchased, and the liquid form of doxepin hydrochloride, commonly used as a sleep agent. During the same meeting, ASCH, along with UC-1 and another FBI agent acting in an undercover capacity (“UC-2”), conducted surveillance of UC-3, the intended victim, as she left her purported work place. ASCH, upon viewing UC-3, said, “She has to die.”

ASCH also introduced UC-1 to MELTZ, who participated in multiple conversations with both UC-1 and ASCH about the conspiracy’s objective to kidnap and commit acts of violence against women. For example, after MELTZ and ASCH discussed the widespread availability of stun guns in gun shops in New Hampshire, where MELTZ lived, and at gun shows in Pennsylvania, and MELTZ provided advice about the use of a stun gun in the commission of the kidnapping offense, ASCH traveled from New York to Pennsylvania to attend a gun show and purchased a high-voltage taser gun.

Throughout this investigation, the FBI intercepted numerous phone calls during which MELTZ provided advice, information, and assistance to ASCH on how to avoid detection and minimize the risks associated with abducting and murdering a woman. Examples of the techniques suggested by MELTZ include the avoidance of toll roads, using rental cars, paying for “tools” in cash, looking for victims in desolate areas who are engaged in other activities (such as talking on the phone), abducting victims at night, and using disguises when first approaching a potential victim.

On April 14, 2013, MELTZ met with UC-1 at a location in New Jersey. This meeting was recorded and observed by FBI agents. At the meeting, MELTZ and UC-1 discussed the kidnapping and murder of UC-3. MELTZ advised UC-1 on how best to dispose of UC-3’s body, including how to transport it from the crime scene to a desolate location in the woods in upstate New York. MELTZ told UC-1 that given the weather at the time of year, if UC-3’s body were left in the woods, wild animals would likely find and destroy it before law enforcement could find it.

On April 15, 2013, ASCH met UC-1 in lower Manhattan to conduct surveillance of UC-3. UC-1 and ASCH previously had discussed ASCH giving UC-1 the tools ASCH had gathered to use for the kidnapping, so that UC-1 could take them to the location where UC-3 was to be brought following her abduction. ASCH brought to the April 15 meeting two bags of tools intended to be used in the kidnapping, rape, torture, and murder of UC-3, including but not limited to a taser gun, rope, a meat hammer, duct tape, gloves, cleaning supplies, zip ties, a dental retractor, two speculums, 12-inch skewers, pliers, a wireless modem, and a leg spreader.

* * *

ASCH, 60, of Manhattan, and MELTZ, 65, of Stanhope, New Jersey, and Nashua, New Hampshire, are each charged with one count of conspiracy to commit kidnapping, which carries a maximum sentence of life in prison, and a maximum fine of $250,000, or twice the gross gain or gross loss from the offense.

Mr. Bharara praised the outstanding investigative work of the FBI. He also thanked the New Jersey State Police. Mr. Bharara added that the investigation is continuing.

This case is being handled by the Office’s Violent Crimes Unit. Assistant United States Attorneys Hadassa Waxman and Brooke E. Cucinella are in charge of the prosecution.

The charges contained in the Complaint and the Indictment against Vanhise are merely accusations, and the defendants are presumed innocent unless and until proven guilty.

13-132

The VA New Jersey Health Care System Police – Providing Law Enforcement and Security Services to:

VHA Lyons, NJ

VHA East Orange, NJ

CBOC Brick, NJ

Lyons East Orange

The United States Veterans Affairs Police in New Jersey, is a fully operational 24/7 police department that provides law enforcement and security to 2 U.S. Veterans Affairs Medical Centers and 8 CBOCs (Community Based Out-Patient Clinic), and currently employees over 45 officers.

Veterans Police Officers are sworn Federal law enforcement who meet U.S. Civil Service (OPM) standards under series 083 (Federal Police Officer).

OIG Office of Healthcare Inspections conducted an inspection in response to a request by the OIG Office of Investigations to review the care of a patient who died unexpectedly while residing at the Mental Health Residential Rehabilitation Treatment Program (MH RRTP) at the VA New Jersey Health Care System (facility), Lyons, NJ. The Office of the State of New Jersey Medical Examiner’s autopsy report listed “Acute intoxication due to the combined effects of cyclobenzaprine, tramadol, gabapentin, sertraline, hydroxyzine, and amlodipine” as the cause of death. The manner of death (suicide, homicide, accidental) was listed as undetermined and final diagnoses included hypertensive and atherosclerotic cardiovascular disease.
We found that program staff did not comply with Veterans Health Administration and facility requirements for an effective safe medication management program or document the resident’s care sufficiently or timely. We also found that leadership did not provide sufficient professional support for a MH RRTP advanced practice registered nurse (mid-level provider).
We recommended that the Health Care System Director ensures that the facility complies with MH RRTP safe medication management requirements, completes required electronic health record documentation, and provides appropriate follow-up to requests for professional support by MH RRTP mid-level providers.

The culture of lack of accountability prevails at Lyons VA Medical Center

This is the same VA where employees were arrested for selling heroin earlier this year:

NEWARK, N.J. – Seven men with access to two VA medical centers in New Jersey were arrested this morning by special agents of the U.S. Department of Veterans Affairs, Office of Inspector General and the FBI on federal charges alleging they sold illegal drugs to veterans being treated at the centers, U.S. Attorney Paul J. Fishman announced.

The seven defendants were each charged in separate criminal complaints with various counts of distributing controlled substances – including heroin, crack and hydromorphone – at the VA medical centers in East Orange and Lyons, N.J. Five of the men were arrested this morning at the Lyons facility, one was arrested at the East Orange facility and one was arrested at his home. All are expected to make their initial appearances this afternoon before U.S. Magistrate Judge Mark Falk in Newark federal court.

“According to our charges, these seven men abused their access to VA medical facilities to peddle dangerous drugs to other veterans undergoing treatment,” said U.S. Attorney Fishman. “It is tragic that those who have served their country would exploit their fellow veterans.”

“This investigation was initiated by VA OIG two years ago in response to the fatal heroin overdose of a veteran at the VA medical center in Lyons, New Jersey,” said Jeffrey G. Hughes, Special Agent in Charge, U.S. Veterans Affairs, Officer of Inspector General, Northeast Field Office. “Subsequently, the FBI and VA OIG jointly launched an operation which focused on combating the sale of heroin and crack cocaine to patients at Lyons. VA management at Lyons, including VA Police, provided invaluable support during the course of this investigation. We hope anyone selling drugs at VA treatment facilities will realize that we will vigorously pursue them to protect veterans seeking treatment.”

“The Federal Bureau of Investigation, Newark Division and the Department of Veterans Affairs Office of Inspector General conducted a joint investigation targeting the distribution of narcotics on the grounds of VA Hospitals in New Jersey,” said FBI Special Agent in Charge Aaron T. Ford. “As a result of this joint investigation, the FBI and VA OIG have been successful in disrupting the criminal activity occurring on the VA grounds. The Newark Division will continue to work in conjunction with our federal, state and local partners to combat the drug problem.”

The VA medical centers provide a wide range of medical and rehabilitation treatment services to veterans, including drug abuse and additional rehabilitation services, along with vocational training and other social services. According to the complaints, the defendants, each of whom is a veteran with privileged access to the buildings and grounds of the medical centers, sold controlled substances to other veterans receiving services from the centers.

Each count with which the defendants are charged carries a maximum potential penalty of 20 years in prison and a fine of $1 million, or twice the gross gain or loss from the offense. The defendants and counts with which they are charged are as follows:

U.S. Attorney Fishman praised special agents of the Veterans Administration, Office of Inspector General, under the direction of Special Agent in Charge Hughes in Newark, and the FBI, under the direction of Special Agent in Charge Ford in Newark, with the investigation leading to the charges. He also thanked the VA Police for their assistance.

The government is represented by Assistant U.S. Attorney David M. Eskew of the U.S. Attorney’s Office General Crimes Unit in Newark.

The charges and allegations contained in the complaints are merely accusations, and the defendants are presumed innocent unless and until proven guilty.

Let’s not forget that this is the same VA hospital that in 2011 allowed two mental patients to leave campus purchase heroin, shoot up, over dose a third patient who died, and remained on the ward dead for more than 24 hours, before any staff person realized that the third veteran was dead. The two patients were prosecuted for their role in this tragedy.

In the keeping with the finest traditions of lack of accountability at the Department of Veterans Affairs only the veterans have been prosecuted, none of the licensed professionals who are paid to supervise these patients, who didn’t notice that they had left the hospital to go buy the drugs, similarly the fact that this veteran apparently was laying dead for more than a day at the VA, and no staff noticed this, doesn’t bother anyone?

Iraq War Veteran Arrested In Connection With Heroin Overdose Death And Cover–Up

FOR IMMEDIATE RELEASE

August 9, 2012

NEWARK, N.J. – An Iraq war veteran was arrested this morning for allegedly giving heroin to a fellow veteran at a U.S. Department of Veterans Affairs hospital who died of an overdose, and for obstructing the investigation into the death, U.S. Attorney Paul J. Fishman announced.

Ryan Krieger, 28, a former Marine and in-patient resident at the post-traumatic stress disorder ward of the VA Medical Center in Lyons, N.J., was charged by Complaint with distribution of heroin and obstruction. He made his initial appearance today before U.S. Magistrate Judge Cathy L. Waldor in Newark federal court.

According to the Complaint:

On July 1, 2011, Krieger and the overdose victim, identified as “J.Z.,” called a taxi and snuck out of the VA Hospital to buy heroin in Paterson, N.J. They withdrew $500 from J.Z.’s bank account at an ATM machine, and Krieger purchased the heroin from a drug dealer he knew in Paterson. When Krieger and J.Z. returned to the hospital with the heroin, they were joined by another in-patient resident, identified as “R.C.,” and the three of them used the heroin in J.Z.’s room.

In the early hours of July 2, 2011, Krieger, J.Z., and R.C. were continuing to use heroin in J.Z.’s room when J.Z. collapsed and lost consciousness. The Complaint alleges that neither Krieger nor R.C. notified anybody at the VA Hospital. Hospital staff discovered J.Z.’s body in his room the following afternoon. He had died of a heroin overdose. Special agents with VA’s Office of the Inspector General (“VA-OIG”) began an investigation into the circumstances of his death.

Krieger allegedly lied to VA-OIG investigators about his activities on the night of J.Z.’s death, and only admitted his role upon being confronted with physical evidence, including a surveillance video from the ATM machine in Paterson. While he agreed to cooperate with the investigation, he allegedly told an individual at the VA hospital months later that he had administered the heroin to J.Z., and that when J.Z. appeared to overdose, Krieger did not seek help, but propped J.Z. up in his bed to create the appearance that J.Z. had taken the heroin himself and overdosed by himself.

The drug distribution count with which Krieger is charged is punishable by a maximum potential prison term of 20 years and a $1 million fine. The obstruction charge is punishable by a maximum potential prison term of 20 years and a $250,000 fine or twice the gain or loss caused

The US Attorney was willing to try to drop kick the veteran, a mental patient, through the goal posts of life, by threatening 40 years in prison and $1,250,000 in fines. Meanwhile all the licensed professionals who were supposed to be protecting these patients from doing this, not only escaped criminal prosecution, but have not been held accountable in any fashion. Even worse, the death of this veteran, the fact that the staff didn’t notice that two mental patients slipped out of the hospital unnoticed for hours, that they returned unnoticed, that they had an unnoticed drug party, and that the death of a patient went unnoticed, all went unnoticed when it came time to give out bonuses. The Director of the NJ VA Health System, Kenneth H. Mizrach who is responsible for the Lyons, NJ and East Orange VA hospitals, a $3,500 bonus for 2011.

I’m certainly not saying that its right for patients to sneak out and buy heroin, but let’s remember, there is a reason why patients are patients at a mental health facility. They obviously have issues that affect their judgment and the ability to exercise it appropriately. That is one of the reasons why there there is a professional staff at a mental health facility, to help protect the patients from themselves. In this case they clearly failed, and no one has been held accountable.

While we are discussing Lyons’ legendary lack of accountability, I would be remiss if I did not point out one the Lyons VA’s most infamous recent alumni:

Richard Meltz

In case you’ve forgotten, he was arrested on April 15, 2013 and charged with attempted rape, kidnapping and attempted murder of several individuals by the US attorney for the Southern District of New York. Meltz was at the time the police chief for the Bedford, Massachusetts VA Medical Center. Prior to that he had been employed at the Lyons VA as a sergeant and held the position as firearms instructor.

Despite the fact that he had been promoted and left the Lyons New Jersey VA, and even more surprisingly despite the fact that he had been arrested on April 15, 2013 ,on September 22, 2013 the Lyons New Jersey VA Police Department’s unofficial website still features a picture of Richard Meltz indicating that he is a sergeant and a firearms instructor at the Lyons, NJ VA.

Lyons NJ VA Police Department web site lists Richard Meltz as sergeant and firearms instructor five months after his arrest for kidnapping!

There is simply no level of accountability whatsoever at Lyons VA and it simply doesn’t bother anyone there to be associated with someone who has been arrested for attempted kidnapping. One would think that they would have taken his photo down the day that he was arrested, but maybe their proud to be associated with him.

PITTSBURGH — In an unusual standoff, the Department of Veterans Affairs has failed for more than a year to answer requests for information from Republicans and Democrats in Congress, including emails relating to the death of at least five patients who were exposed to Legionnaires’ disease in the Pittsburgh VA system.

The House Committee on Veterans Affairs called a special hearing Thursday to grill a top VA official about the problem and even threatened to cut funding if the situation doesn’t improve.

“Frustration has been brewing for months,” said committee chairman Jeff Miller, a Florida Republican. A Democrat from a different part of the country agreed.

Committee members “are frustrated and unhappy” with the VA’s handling of requests for records, said Rep. Mike Michaud, a Maine Democrat.

It’s not a typical Washington political spat, said Elaine Kamarck, an expert at the Brookings Institution think tank and former White House staff member during the Clinton administration.

“The fact that the requests have been bipartisan does raise a flag. It does make you wonder what’s going on at VA,” said Kamarck, adding that “in a town where there is partisan polarization over just about anything, when both parties are critical of something, you know there’s cause for concern.”

According to committee members who spoke at the Thursday hearing, the VA is foot-dragging on more than 70 requests for information, some of which relate to investigations into preventable veteran deaths and delays in care at VA medical facilities around the country.

“We can, we must and we will do better,” replied Joan M. Mooney, the VA assistant secretary for congressional and legislative affairs.

Mooney said that her Washington office has responded to tens of thousands of congressional requests for information since the 2009 fiscal year, but Miller noted that the office has been given a 40 percent increase in staff, too.

“If things don’t improve materially, this committee will have no choice but to reconsider the funding your office receives,” Miller said.

In response to questions from The Associated Press, the VA provided a copy of Mooney’s testimony to the committee and said in a statement that it provides “an incredible volume of information to Congress on a daily basis.”

The standoff is highly unusual, partly because the committee “is the hand that feeds” the VA, since the Constitution gives Congress the responsibility for oversight of federal agencies, said Pat Dunham, a professor of political science at Duquesne University in Pittsburgh.

Congressman Tim Murphy, a Republican who represents a Pittsburgh-area district, said in a statement that “to date, the VA has not been cooperative. On behalf of the families who lost loved ones, the VA must be more forthcoming, and demonstrate a sustained commitment to fulfilling their obligations to congressional investigations.

(CBS News) On Friday, the chairman of the House Veterans Affairs Committee called for immediate action after a CBS News investigation that we brought you Thursday.

Jim Axelrod’s story showed that many returning war veterans are receiving lethal amounts of pain medication from VA hospitals.

In that story, we met Heather McDonald, who said she found the body of her husband, Scott, after he followed directions for taking a series of prescribed drugs.

“He never should have been taking those many pills,” she said. “But he trusted his doctors, and if they said jump, he did because he thought it was gonna make him better. My husband served honorably, and with pride and dignity. Not to come home and die on the couch.”

After seeing our report, House Veterans Affairs Committee Chairman Jeff Miller said the VA’s approach to pain management is in dire need of an overhaul. He said the committee will hold hearings to fix the problems and hold those responsible to account.

Dr. Hollenbeck works at a VA medical center in Jackson, Mississippi and has raised her concerns with the federal government, which apparently blew her off.

“The people in charge said, ‘We want you to sign off on narcotic prescriptions on patients you don’t see.’ I was absolutely stunned. And I knew immediately it was illegal. It works on the surface. It keeps the veterans happy. They don’t complain. They’re not coming in as often if they have their pain medicine. And the people in charge don’t care if it’s done right,” added Dr. Hollenbeck.

The number of patients treated by the VA over the past 11 years is up 29 percent and narcotics prescriptions are up a whopping 259 percent, reports CBS News.

Former service men and women accidentally overdose from narcotics at a 33 percent higher rate than people who are non-veterans in the five states with the highest number of vets.

“I have seen people that have not had an exam of that body part that they’re complaining of pain in for two years. It’s easier to write a prescription for narcotics, and just move along, get to the next patient,” said a VA doctor, who didn’t want to be identified.

“We’re letting people come in and prescribing massive doses of narcotics and they also are on drugs for mental health problems.”

Dr. Robert Kerns, director of pain management for the VA, responded the statistics: “Providers are trained to have a thoughtful discussion with their patient to share concerns about the limited potential benefit of these medications, but also these risks that we are talking about today.